Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women’s autonomy should be respected, and that plans around birth should be personalised. However, there appear to be profound challenges in practice to respecting women’s choices in pregnancy and labour. Choices carry risks and consequences—to the woman and her child; also potentially to her caregivers and to other women.What does it mean for women’s autonomy to be respected in (...) obstetrics? How should health professionals respond to refusals of treatment or requests for care outside normal guidelines? What are the ethical limits to autonomy? In this clinical ethics round table, service users, midwives, obstetricians, philosophers and ethicists respond to two hypothetical cases drawn from real-life scenarios. (shrink)

Children dependent on life-prolonging medical technology are often subject to a constant background risk of sudden death or catastrophic complications. Such children can be cared for in hospital, in an intensive care environment with highly trained nurses and doctors able to deliver specialised, life-saving care immediately. However, remaining in hospital, when life expectancy is limited, can considered to be a harm in of itself. Discharge home offers the possibility for an improved quality of life for the child and their family (...) but comes with significant medical risks.When making decisions for children, two ethical models predominate, the promotion of the child’s best interests or the avoidance of harm. However, in some circumstances, particularly for children with life-limiting and/or life-threatening illness, all options may be associated with risk. There are no good options, only potentially harmful choices.In this paper, we explore decisions made by one family in such circumstances. We describe a model adopted from risk management programmes beyond medicine, which offers a potential framework for identifying risks to the child that are morally permissible. Some risks and harms to a child, not ordinarily permitted, may be acceptable when undertaken in the pursuit of a specified desired good, so long as they are as low as reasonably practicable. (shrink)

Infants are unable to make their own decisions or express their own wishes about medical procedures and treatments. They rely on surrogates to make decisions for them. Who should be the decision-maker when an infant’s biological parents are also minors? In this paper, we analyse a case in which the biological mother is a child. The central questions raised by the case are whether minor parents should make medical decisions on behalf of an infant, and if so, what are the (...) limits to this decision-making authority? In particular, can they refuse treatment that might be considered best for the infant? We examine different ethical arguments to underpin parental decision-making authority; we argue that provided that minor parents are capable of fulfilling their parental duties, they should have a right to make medical decisions for their infant. We then examine the ethical limits to minor parents’ decision-making authority for their children. We argue that the restricted authority that teenagers are granted to make medical decisions for themselves looks very similar to the restricted autonomy of all parents. That is, they are permitted to make choices, but not harmful choices. Like all parents, minor parents must not abuse or neglect their children and must also promote their welfare. They have a moral right to make medical decisions for their infants within the same ‘zone of parental discretion’ that applies to adult parents. We conclude that adult and minor parents should have comparable decision-making authority for their infants. (shrink)

The COVID-19 pandemic crisis has necessitated widespread adaptation of revised treatment regimens for both urgent and routine medical problems in patients with and without COVID-19. Some of these alternative treatments maybe second-best. Treatments that are known to be superior might not be appropriate to deliver during a pandemic when consideration must be given to distributive justice and protection of patients and their medical teams as well the importance given to individual benefit and autonomy. What is required of the doctor discussing (...) these alternative, potentially inferior treatments and seeking consent to proceed? Should doctors share information about unavailable but standard treatment alternatives when seeking consent? There are arguments in defence of non-disclosure; information about unavailable treatments may not aid a patient to weigh up options that are available to them. There might be justified concern about distress for patients who are informed that they are receiving second-best therapies. However, we argue that doctors should tailor information according to the needs of the individual patient. For most patients that will include a nuanced discussion about treatments that would be considered in other times but currently unavailable. That will sometimes be a difficult conversation, and require clinicians to be frank about limited resources and necessary rationing. However, transparency and honesty will usually be the best policy. (shrink)

Parents who are facing decisions about life-sustaining treatment for their seriously ill or dying child are supported by their child's doctors and nurses. They also frequently seek other information sources to help them deal with the medical and ethical questions that arise. This might include written or web-based information. As part of a project involving the development of such a resource to support parents facing difficult decisions, some ethical questions emerged. Should this information be presented in a strictly neutral fashion? (...) Is it problematic if narratives, arguments or perspectives appear to favour stopping over continuing life-sustaining treatment? Similar questions might arise with written materials about decisions for adults, or for other ethically contentious decisions. This paper explores the meaning of ‘balance’ in information provision, focusing particularly on written information about life-sustaining treatment for children. We contrast the norm of non-directiveness in genetic counselling with the shared decision-making model often endorsed in end-of-life care. We review evidence that parents do not find neutrality from medical professionals helpful in discussions. We argue that balance in written information must be understood in the light of the aim of the document, the most common situation in which it will be used, and any existing biases. We conclude with four important strategies for ensuring that non-neutral information is nevertheless ethically appropriate. (shrink)

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues (...) associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are ‘fit for reallocation’ have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated. (shrink)

T. 1. Pourquoi ? -- t. 2. ABC -- t. 3. DEFGHI -- t. 4. JKLMNO -- t. 5. PQRS -- t. 6. TUVWXYZ -- t. 7. Annexes-Exils.

There is a growing call for greater public involvement in establishing science and technology policy, in line with democratic ideals. A variety of public participation procedures exist that aim to consult and involve the public, ranging from the public hearing to the consensus conference. Unfortunately, a general lack of empirical consideration of the quality of these methods arises from confusion as to the appropriate benchmarks for evaluation. Given that the quality of the output of any participation exercise is difficult to (...) determine, the authors suggest the need to consider which aspects of the process are desirable and then to measure the presence or quality of these process aspects. To this end, a number of theoretical evaluation criteria that are essential for effective public participation are specified. These comprise two types: acceptance criteria, which concern features of a method that make it acceptable to the wider public, and process criteria, which concern features of the process that are liable to ensure that it takes place in an effective manner. Future research needs to develop instruments to measure these criteria more precisely and identify the contextual and environmental factors that will mediate the effectiveness of the different participation methods. (shrink)

The University of Pittsburgh Medical Center (UPMC) "Policy for the Management of Terminally Ill Patients Who May Become Organ Donors after Death" proposes to take organs from certain patients as soon as possible after expected cardiopulmonary death. This policy requires clear understanding of the descriptive state of the donor's critical cardiopulmonary and neurologic functional capacity at the time interventions to sustain or harvest organs are undertaken. It also requires strong consensus about the moral and legal status of the donor during (...) dying and confirmation of death. There has been no need for the clarity and precision that this policy relies upon, and thus the needed research and conceptual work has not previously been generated. The empiric base and societal consensus are both too frail to provide justification for this policy at this time. (shrink)

In this article, we critique two theoretical positions that analyze the place of emotions in education: the psychological strand and the cultural feminist strand. First of all, it is shown how a social control of emotions in education is reflected in the combination of psychological and cultural feminist discourses that function to govern one’s self effectively and efficiently. These discourses perpetuate an assumed divide between the rational and the emotional, and reinforce the existing power hierarchies and the status quo of (...) stereotypes about the role of emotion in education. Then we use the Foucauldian notions of parrhesia and care of the self to suggest alternative ways of thinking about emotions in education. Instead of campaigning for one side or the other of the rational/emotional divide, we suggest that it may be more interesting and fruitful to examine the particular ways discourses of emotion in education construct their own brand of parrhesia. (shrink)

In “Ethics Consultation in U.S. Hospitals: Opinions of Ethics Practitioners,” Fox and colleagues note that despite efforts of the American Society for Bioethics and Humanities to impr...

One cue that may facilitate children's word learning is iconicity, or the correspondence between a word's form and meaning. Some have even proposed that iconicity in the early lexicon may serve to help children learn how to learn words, supporting the acquisition of even noniconic, or arbitrary, word–referent associations. However, this proposal remains untested. Here, we investigate the iconicity of caregivers’ speech to young children during a naturalistic free‐play session with novel stimuli and ask whether the iconicity of caregivers’ speech (...) facilitates children's learning of the noniconic novel names of those stimuli. Thirty‐four 1.5‐2‐year‐olds (19 girls; half monolingual English learners and half bilingual English‐Spanish learners) participated in a naturalistic free‐play task with their caregivers followed by a test of word‐referent retention. We found that caregivers’ use of iconicity, particularly in utterances in which they named the novel stimuli, was associated with the likelihood that children learned that novel name. This result held even when controlling for other factors associated with word learning, such as the concreteness and frequency of words in caregiver speech. Together, the results demonstrate that iconicity not only can serve to help children identify the referent of novel words (as in previous research) but can also support their ability to retain even noniconic word‐referent mappings. (shrink)

Professor Copi provides us with the following example:Remove all cards except aces and kings from a deck, so that only eight cards remain, of which four are aces and four are kings. From this abbreviated deck, deal two cards to a friend. If he looks at his cards and announces that his hand contains an ace, what is the probability that both his cards are aces? If he announces instead that one of his cards is the ace of spades, what (...) is the probability then that both his cards are aces? (shrink)

Appeals to some thesis of underdetermination, to the idea that scientific theories and hypotheses are not entailed by the evidence that supports them, are common in feminist philosophy of science. These appeals seek to understand and explain how androcentrism and other problematic approaches to gender have found their way into good science, as well as the reverse – how feminist approaches to gender and science that are also value-laden, can contribute to good science. Focusing on W.V. Quine’s positions on holism (...) and underdetermination, I argue that although Quine’s general thesis of holism does not entail his thesis of global underdetermination, his account of and arguments for moderate holism entail a localized and generalizable underdetermination, which I call moderate underdetermination. This moderate underdetermination is not transient or true of only some theories and hypotheses. Rather, it is a permanent state of affairs that characterizes all reasonably inclusive theories and hypotheses, however much evidence for them accumulates. I contend that Quine’s moderate holism entails the most robust and defensible argument for localized underdetermination, and that feminists would do well to appeal to it in arguing that values inform good science. (shrink)

For a long time, linguists more or less denied the existence of individual differences in grammatical knowledge. While recent years have seen an explosion of research on individual differences, most usage-based research has failed to address this issue and has remained reluctant to study the synergy between individual and community grammars. This paper focuses on individual differences in linguistic knowledge and processing, and examines how these differences can be integrated into a more comprehensive constructionist theory of grammar. The examination is (...) guided by the various challenges and opportunities that may be extracted from scattered research that exists across disciplines touching on these matters, while also presenting some new data that illustrate how differentiation between individuals can improve models of long-term language change. The paper also serves as the introduction to this special issue of Cognitive Linguistics, which collects seven contributions from various linguistic disciplines focusing on key aspects of individuals’ grammars. (shrink)

: "Clinical pragmatism" is an important new method of moral problem solving in clinical practice. This method draws on the pragmatic philosophy of John Dewey and recommends an experimental approach to solving moral problems in clinical practice. Although the method may shed some light on how clinicians and their patients ought to interact when moral problems are at hand, it nonetheless is deficient in a number of respects. Clinical pragmatism fails to explain adequately how moral problems can be solved experimentally, (...) it underestimates the relevance and importance of judgment in clinical ethics, and it presents a questionable account of the role that moral principles should play in moral problem solving. (shrink)

The term “exploitation” has gained wide currency in recent discussions of biomedical and research ethics. This is due in no small measure to the influence of Alan Wertheimer’s path-breaking work on the topic (Wertheimer 1999, 2011). Wertheimer presented a clear and compelling non-Marxist account of the concept of exploitation—one that stressed the connection between exploitation and unfair distributive outcomes. On this account, when one party exploits another, she takes advantage of the other to gain unfairly. A number of contemporary bioethicists (...) have accepted Wertheimer’s account of exploitation and have proceeded to apply it to a range of issues in research ethics (Hawkins and Emanuel 2008; Miller and Brody .. (shrink)

Unrealistic optimism is a bias that leads people to believe, with respect to a specific event or hazard, that they are more likely to experience positive outcomes and/or less likely to experience negative outcomes than similar others. The phenomenon has been seen in a range of health-related contexts—including when prospective participants are presented with the risks and benefits of participating in a clinical trial. In order to test for the prevalence of unrealistic optimism among participants of early-phase oncology trials, we (...) conducted a survey with patients over 18 years of age who were enrolled in a phase I, phase I/II, or phase II clinical cancer trial in the New York City area between August 2008 and October 2009. Participants in our study were asked to compare their own chances of experiencing a range of risks and benefits related to the trial they were enrolled in with the chances of the other trial participants. We found a significant optimistic bias in their responses. Respondents tended to overestimate the benefits of the trial they were enrolled in and underestimate its risks. In addition, we found no significant relationship between respondents’ understanding of the trial’s purpose and how susceptible they were to unrealistic optimism. Our findings suggest that improving the consent process for oncology studies requires more than addressing deficits in understanding. (shrink)

BackgroundFor children with life-limiting conditions who are unable to participate in decision-making, decisions are made for them by their parents and paediatricians. Shared decision-making is widely recommended in paediatric clinical care, with parents preferring a collaborative approach in the care of their child. Despite the increasing emphasis to adopt this approach, little is known about the roles and responsibilities taken by parents and paediatricians in this process. In this study, we describe how paediatricians approach decision-making for a child with a (...) life-limiting condition who is unable to participate in decision-making for his/herself.MethodsThis qualitative phenomenological study involved 25 purposively sampled paediatricians. Verbatim transcripts from individual semi-structured interviews, conducted between mid-2019 and mid-2020, underwent thematic analysis. Interviews were based around a case vignette matched to the clinical experience of each paediatrician.ResultsTwo key themes were identified in the exploration of paediatricians' approach to decision-making for children with life-limiting conditions: there is a spectrum of paediatricians’ roles and responsibilities in decision-making, and the specific influences on paediatricians’ choice of approach for end-of-life decisions. In relation to, analysis showed four distinct approaches: non-directed, joint, interpretative, and directed. In relation to, the common factors were: harm to the child, possible psychological harm to parents, parental preferences in decision-making, and resource allocation.ConclusionsDespite self-reporting shared decision-making practices, what paediatricians often described were physician-led decision-making approaches. Adopting these approaches was predominantly justified by paediatricians’ considerations of harm to the child and parents. Further research is needed to elucidate the issues identified in this study, particularly the communication within and parental responses to physician-led approaches. We also need to further study how parental needs are identified in family-led decision-making approaches. These nuances and complexities are needed for future practice guidance and training around paediatric decision-making.Trial registration: Not applicable. (shrink)

Predictions of poor prognosis for critically ill patients may become self-fulfilling if life-sustaining treatment or resuscitation is subsequently withheld on the basis of that prediction. This paper outlines the epistemic and normative problems raised by self-fulfilling prophecies (SFPs) in intensive care. Where predictions affect outcome, it can be extremely difficult to ascertain the mortality rate for patients if all treatment were provided. SFPs may lead to an increase in mortality for cohorts of patients predicted to have poor prognosis, they may (...) lead doctors to feel causally responsible for the deaths of their patients, and they may compromise honest communication with patients and families about prognosis. However, I argue that the self-fulfilling prophecy is inevitable when life-sustaining treatment is withheld or withdrawn in the face of uncertainty. SFPs do not necessarily make treatment limitation decisions problematic. To minimize the effects of SFPs, it is essential to carefully collect and appraise evidence about prognosis. Doctors need to be honest with themselves and with patients and their families about uncertainty and the limits of knowledge. (shrink)

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are alternatives, (...) Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies. (shrink)

There is a lack of published evidence which demonstrates the impacts of public engagement in science and technology policy. This might represent the failure of PE to achieve policy impacts or indicate a lack of effective procedures for discerning the uptake by policy makers of PE-derived outputs. While efforts have been made to identify and categorize different types of policy impact, research has rarely attempted to link policy impact with PE procedures, political procedures, or the connections between them. In this (...) article, we propose a simple conceptual model to capture this information, based on semistructured interviews with both policy makers and PE practitioners. A range of criteria are identified to increase the policy impact of PE. The role of PE practitioners in realizing impacts through their interactions with policy makers in the informal “in-between” spaces of public engagement is emphasized. However, the potential contradictions between the pursuit of policy impacts and the more traditional conceptualizations of PE effectiveness are discussed. The main barrier to the identification of policy impacts from PE may lie within policy processes themselves. Political institutions have responsibility to establish formalized procedures for monitoring the uptake and use of evidence from PE in their decision-making processes. (shrink)

Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill (...) that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill. (shrink)

This paper examines, on the basis of a longitudinal corpus of 50 early modern authors, how change at the aggregate level of the community interacts with variation and change at the micro-level of the individual language user. In doing so, this study aims to address the methodological gap between collective change and entrenchment, that is, the gap between language as a social phenomenon and the cognitive processes responsible for the continuous reorganization of linguistic knowledge in individual speakers. Taking up the (...) case of the prepositional passive, this study documents a strong community-wide increase in use that is accompanied by increasing schematicity. A comparison of the 50 authors reveals that regularities arising at the macro-level conceal highly complex and variable individual behavior, aspects of which may be explained by studying the larger (social) context in which these individuals operate (e. g., age cohorts, community of practice, biographical insights). Further analysis, focusing on how authors use the prepositional passive in unique and similar ways, elucidates the role of small individual biases in long-term change. Overall, it is demonstrated that language change is an emergent phenomenon that results from the complex interaction between individual speakers, who themselves may change their linguistic behavior to varying degrees. (shrink)

In theory, HREC members should use the ethical guidelines in the National Statement on the Ethical Conduct of Research Involving Humans as the basis for their decisions, and researchers should design their research in accordance with these guidelines However, very little is known about what researchers and HREC members actually do in practice. In this paper, we report some of the key findings of the study “Human Research Ethics in Practice”, a qualitative interview-based study of health researchers and HREC members (...) in Victoria. The findings shed light on how researchers and HREC members conceptualise ethics, how they use the National Statement, and what deliberative strategies they employ to assess the ethical appropriateness of research studies. The findings also reveal differences and similarities between health researchers’ and HREC members’ perceptions of the roles of HRECs, and point to some sources of misunderstanding and tension. We examine the implications of some of these findings for the ways in which HRECs carry out their task, and research institutions support and promote ethical conduct in research amongst their staff and students. The focus of this study is on health research, but we suggest that the findings are highly relevant to all other research areas where human participants are involved. (shrink)

How do engineers respond to ethical dilemmas that occur in practice? How do they view their individual and collective responsibilities? How do they make decisions before all the facts are in? Using the space shuttle programme as the framework, this book examines the role of ethical decision making in the practice of engineering. In particular, the book considers the design and development of the main engines of the space shuttle as a paradigm for how individual engineers perceive, articulate, and resolve (...) ethical dilemmas in a large, complex organisation. A series of in-depth case studies show engineers at work on various stages of the project as they balance budgets, deadlines and risks. By documenting the historical development of a single system, the book provides a unique opportunity to explore the complex interactions between political, organisational and technical pressures and engineering and management decisions. (shrink)

If people sometimes participate in research because of altruism—because they want to help in the search for treatments—should we revise our views about what kinds of experiments are ethical? If participants act out of altruism, we might let them accept greater risks than we would if they are motivated only by a desire for personal gain. But how can we know when participants are genuinely altruistic?

Some commentators have recently proposed that “clinical equipoise,” although widely accepted, is not necessary for morally acceptable research on human subjects. If this concept is rejected, however, we may find that trials not in the best medical interests of their subjects—”bad deal trials”—could be justified. To avoid exploiting participants, we must find a way to distribute the risks fairly, even if it means embracing radical changes in the way clinical research is conducted.

Gametes, tissue, and organs can be taken from the dying or dead for reproduction, transplantation, and research. Whole bodies as well as parts can be used for teaching anatomy. While these uses are diverse, they have an ethical consideration in common: the claims of the people whose bodies are used. Is some use permissible only when people have consented to the use, actually wanted the use, would have wanted the use, not opposed the use, or what? The aim of this (...) article is to make progress in answering these questions. Initially I assume knowledge of people’s desires in order to test whether consent is directly required by their rights without worrying about mistaken uses against their wishes. I claim consent is not directly required by people’s rights. If we know people wanted or would want a use, their rights permit the use, but if we know they wanted or would want not to be used, their rights do not permit the use. The knowledge assumption is then dropped and the question becomes how to decide what to do when the wishes of rightholders are not known. I suggest working out what to do when wishes are known and then adjusting, on the basis of whatever evidence there is, for probability and strength of desire. There are other considerations too, for instance about default rules. The key general comment here is that, in setting rules, the costs to rightholders in not getting what they want needs to be taken into account. The final section tries to show that, in setting these rules, mistaken uses are not to be taken as worse than mistaken failure to use. (shrink)

In the UK, female genital mutilation is unlawful, not only when performed on minors, but also when performed on adult women. The aim of our paper is to examine several arguments which have been advanced in support of this ban and to assess whether they are sufficient to justify banning female genital mutilation for competent, consenting women. We proceed by comparing female genital mutilation, which is banned, with cosmetic surgery, towards which the law has taken a very permissive stance. We (...) then examine the main arguments for the prohibition of the former, assessing in each case both (a) whether the argument succeeds in justifying the ban and, if so, (b) whether a parallel argument would not also support a ban on the latter. We focus on the following arguments. Female genital mutilation should be unlawful because: (1) no woman could validly consent to it; (2) it is an oppressive and sexist practice; (3) it involves the intentional infliction of injury; (4) it causes offence. Our view is that arguments (3) and (4) are unsound and that, although arguments (1) and (2) may be sound, they support not only a ban on female genital mutilation, but also one on (some types of) costmetic surgery. Hence, we conclude that the present legal situation in the UK is ethically unsustainable in one of the following ways. Either the ban on female genital mutilation is unjustified because arguments (1) and (2) are not in fact successful; or the law's permissive attitude towards cosmetic surgery is unjustified because arguments (1) and (2) are in fact successful and apply equally to female genital mutilation and (certain forms of) cosmetic surgery. The people of the countries where female genital mutilation is practised resent references to ‘barbaric practices imposed on women by male‐dominated primitive societies’, especially when they look at the Western world and see women undergoing their own feminization rites intended to increase sexual desirability: medically dangerous forms of cosmetic plastic surgery, for instance …. (shrink)

In many forms of severe acute brain injury there is an early phase when prognosis is uncertain, followed later by physiological recovery and the possibility of more certain predictions of future impairment. There may be a window of opportunity for withdrawal of life support early, but if decisions are delayed there is the risk that the patient will survive with severe impairment. In this paper I focus on the example of neonatal encephalopathy and the question of the timing of prognostic (...) tests and decisions to continue or to withdraw life-sustaining treatment. Should testing be performed early or later; and how should parents decide what to do given the conflicting values at stake? I apply decision theory to the problem, using sensitivity analysis to assess how different features of the tests or different values would affect a decision to perform early or late prognostic testing. I draw some general conclusions from this model for decisions about the timing of testing in neonatal encephalopathy. Finally I consider possible solutions to the problem posed by the window of opportunity. Decision theory highlights the costs of uncertainty. This may prompt further research into improving prognostic tests. But it may also prompt us to reconsider our current attitudes towards the palliative care of newborn infants predicted to be severely impaired. (shrink)